Comprehensive Case Study- 13-Year-Old Boy With Testicular Pain (CLASS 6512) iHuman Case Analysis W

I Human Case Week #10 13-Year-Old Reason For Encounter: Testicular Pain With Screenshots (Class 6512) 2024

HPI: A 13-year-old boy who presented to the clinic with his father with a 2 hour history of sudden onset of pain in the left scrotum/testicular area following the physical activity of playing basketball. He reports that the pain is constant and rates it as a 9 on a scale of 0-10. He also reports associated nausea with one episode of vomiting related to the onset of his testicular pain. He also reports difficulty walking due to the pain in his scrotum. No associated trauma related to the testicular pain was reported. No other symptoms were reported, and he states no treatment for the pain and associated nausea has been utilized.

Problem Statement A 13-years-old boy came to the clinic with his father, with a complaint of testicular pain. The patient stated that a sudden pain in his left testicle started two hours ago when he was playing the basketball match. The pain is persistent and increases when he walks or moves. He is also experiencing nausea and had vomited once. Patient has not taken any medication for the pain. Patient rated the pain 9 at the pain scale of 0-10.

Current Medications: None Allergies: No allergies reported Pertinent PMHx: Patient has been in general good health.

Medical, surgical, obstetric, hospitalizations: Tympanostomy tubes as a young child No other hospitalizations, surgeries, ER visits, or specialist provider visits noted.

Vaccinations: Immunizations up to date for his age.

Developmental: Cognitive stage: Formal Operational Stage (12 years of age and over) With this stage of development at 12 years of age children can follow the form of a logical argument without the reference to its content. Also, during this time, children can develop the abilities to think about abstract concepts and also test hypothetical problems and develop solutions to these problems. Also, children ‘s concrete operations are carried out on things and formal operations are carried out on ideas. It is also understood that formal operational thought is entirely freed from physical perceptual constraints.

Psychosocial: Erikson’s Stage 5 Identity vs. Role Confusion (Age12 years - 18 years) This stage occurs during adolescence or the ages of 12 years to 18 years. During this time, they transition from childhood to adulthood, and become more independent, look to the future in terms of career, develop relationships, and look to the future concerning families and housing. According to Erikson, adolescents may also feel uncomfortable about their bodies until they can adapt to the changes. It is also

understood at this stage adolescents explore possibilities and begin to develop their own identities. They may also have an identity crisis or experiment with different lifestyles such as in work, education, or political activities.

Soc Hx: Marital status/personal support system: dependent adolescent Housing: lives in a single-family home with sister and both parents Occupation: middle-school student Substance use (tobacco, alcohol, other substances): none Pertinent sexual history: not sexually active Fam Hx: Father: age 49; hypertension Mother: age 48; no medical problems Siblings: sister age 9; healthy Spouse/offspring: N/A History questions asked:

1. How can I help you today?

2. Is your urine pink or red in color (blood in urine)?

3. Do you have pain/discomfort when you urinate?

4. Any change in the frequency of your bowel movements?

5. Do you have any pain in your leg(s)?

6. Do you have any pain in your abdomen?

7. Have you been having fevers?

8. Do you have any problems with movement?

9. Do you have any other symptoms or concerns we should discuss?

10. Do you have any pain in your back?

11. Have you had any trauma to your groin?

12. How is your appetite? Any recent change?

13. When did your testicular pain start?

14. What are the events surrounding the start of your testicular pain?

15. What does your testicular pain feel like?

16. Does your testicular pain come and go?

17. How severe (1-10) is your testicular pain?

18. Are you taking any prescription medications?

19. Have you ever been diagnosed with a hernia?

20. Are you taking any over-the-counter or herbal medications?

21. Do you have any allergies?

22. How is your family and family life?

23. Are you sexually active?

24. Are there any diseases that run in your family?

25. Have you noticed any bruising, bleeding gums, nose bleeds, or other sites of increased bleeding?

26. Do you have problems with heat or cold intolerance, increased thirst, increased sweating, frequent urination, or change in appetite?

27. Do you have problems with dizziness, fainting, spinning room, seizures, weakness, numbness, tingling, or tremor?

28. Do you have any problems with fatigue, difficulty sleeping, unintentional weight loss or gain, fevers, or night sweats?

29. Do you have any problems with headaches that don’t go away with aspirin or Tylenol (acetaminophen), double or blurred vision, difficulty with night vision, or problems hearing?

General/Constitutional:

•

Positive for pain and restlessness. Negative for fatigue. Negative for weight loss, chills.

Communicative.

HEENT/Neck:

• •

See HPI Negative for instances of double vision and blurred vision. Negative for yellow sclerae. Ears, Nose, Throat: No hearing loss, sneezing, congestion, runny nose, or sore throat.

Integumentary: • Negative for rash or burning. Negative for change in skin pigmentation.

Cardiovascular • Negative for chest pain, pressure, or discomfort. Negative for dyspnea, palpitations, or edema.

Respiratory: • Negative for cough, dyspnea, or sputum.

Abdomen/Gastrointestinal: • Positive for nausea and vomiting. Negative for diarrhea, and loss of appetite. Negative for abdominal pain or blood in stool.

Genitourinary:

•

Positive for pain in left scrotum/testicle. Negative for dysuria, frequency, trouble with stream, or hematuria .

Objective: Physical exam: VS: HT: 5’ 5" WT- 120 lbs (55 kg). (70th Percentile), Temp-97.6 F, BP – 130/70, BMI 17.9, Pulse- 120, RR 18.

General:

Well-built 13-year-old Male. Appears uncomfortable and in pain. Answers questions appropriately.

Integumentary: Overall skin warm and intact. Slightly diaphoretic. Some acne on face and back. No lesions or rashes noted.

HEENT/Neck: Eyes without redness, discharge. Normocephalic; no dysmorphic features PERRLA, EOM intact No strabismus TM's intact/clear No tonsillar hypertrophy; normal vocal tone Thyroid WNL for size and consistency; no palpable nodules No cervical lymphadenopathy Cardiovascular: Tachycardic, rhythm regular. No evidence of murmur. No evidence of peripheral edema.

Abdomen/Gastrointestinal: Abdomen is soft and nontender. Negative for organomegaly. No abdominal or inguinal mass.

Lymphatic: No inguinal adenopathy Genitourinary: Left hemiscrotum edematous and mildly erythematous Left testicle appears higher than the right and the scrotum is too swollen to determine testicular lie Left testicle exquisitely tender to touch with no masses noted Absent left cremasteric reflex Negative Prehn’s sign No rash or lesions Psychological: Cooperative. Answers questions appropriately.

Diagnostic results: Scrotal ultrasound doppler showed absent blood flow to affected left testicle CBC with differential was abnormal with mildly increased WBC

Urinalysis was normal CT of abdomen and pelvis without contrast was negative

Assessment: Differential Diagnoses Primary Diagnosis and ICD-10 code: Primary- Testicular Torsion ICD:10 code N44.00 Torsion of testis, unspecified Testicular torsion is known as an issue when a testicle rotates and twists the cord supplying blood to the scrotum. And this is known to occur after vigorous activity, a minor injury to the testicle, or can occur during sleep. It is also known to mostly occur in children within the age groups of 12-15 years (Tanaka, Ogasawara, Nikai, Yamada, Fujiwara, & Okazaki, 2020). Testicular torsion is deemed a surgical emergency that, in case of delay or misdiagnosis, can lead to the loss of the affected testicle and consequently requires an emergency assessment and a possible surgical intervention in the child (Abbas, Abdelkareem, & Alhadi, et al., 2018). It is also known to account for 10 to 15 percent of acute scrotal ailments that occur in children (Abbas, Abdelkareem, & Alhadi, et al., 2018). Diagnosis is most commonly made with a scrotal doppler, and it is important that proper diagnosis is made within 6 hours to prevent testicular loss. A Urologist consult is indicated. Also, sending the child to surgery for testicular exploration prior to confirming diagnosis with scrotal doppler ultrasound is ok, and treatment will include pain and nausea control, as well as surgical intervention to untwist the affected spermatic cord, and it may be also necessary to stitch the affected testicle to the inside of the scrotum to prevent torsion from happening again.

Differential Diagnoses: Inguinal Hernia ICD:10 code K40.91 Unilateral inguinal hernia, without obstruction or gangrene An inguinal hernia is known as tissue or part of the intestine that protrudes through the abdominal muscles or within the groin area. It is more commonly known to occur in men than within women, and can also be indirect, or occurs prior to birth. Individuals who have a higher body mass are at a higher risk of developing an inguinal hernia (Shrestha & Upadhyay, 2021). Heavy work that includes heavy lifting, straining, or heavy coughing with sputum are also risk factors to the development of an inguinal hernia (Shrestha & Upadhyay, 2021). The diagnosis of an inguinal hernia is made with asking a thorough family history and also with a CT scan of the abdomen and pelvis. Treatment usually includes surgery such as an open hernia repair, a laparoscopic hernia repair, and can include mesh and stitching to strengthen the abdominal wall or the area of the groin (Estridge, Sanders, & Kingsnorth, 2019). This is not the likely diagnosis for the patient C.M. due to the CT of the abdomen and pelvis being negative. A hernia was also not palpated on his physical assessment.

Urolithiasis ICD:10 code N20.9 Urinary calculus, unspecified Urolithiasis or nephrolithiasis is known to include calculi or stones that occur within the body of the kidneys and the prevalence is known to occur most often within the male population, and those individuals within the age group of 50-60 (Courbebaisse, Prot-Bertoye, & Daudon, 2020). However, they can occur in females and in the younger population. The severe, intermittent pain triggered by kidney stones is called renal colic and occurs due to

contraction of the smooth muscle of the ureter as an attempt to move the stone (Cunningham, Noble, Al-Modhefer, & Walsh, 2016). Diagnosis of nephrolithiasis or kidney calculi is known to include a through medical history, CMP, CBC, abdominal ultrasound, urinalysis, or a CT scan if needed. Symptoms can sometimes present mimicking other disorders such as cholelithiasis or appendicitis, and have symptoms such as severe pain, nausea and vomiting, and fever. Referred pain to the lower back such as the pain in spinal lumbar area can also occur. Treatment such as hydration, pain medication, antibiotics, and more invasive treatment not found in a primary clinic such as surgical procedures which will require a referral to a Urologist and/or Nephrologist (Bishop, Momah, & Ricks, 2020). This is unlikely to be the diagnosis for C.M. because his urinalysis was normal and the CT of the abdomen and pelvis was negative.

Epididymitis ICD:10 code N45.1 Epididymitis Epididymitis is known as inflammation or infection of the epididymis at the back of the affected testicle.

Epididymitis, testicular torsion, and major epididymo-orchitis can be problematic to differentiate (Devlies, Seghers, & Dilen, 2020). It is known that around 600,000 new cases of epididymitis occur per year within the United States, and most cases occurred in men between 18 and 35 years of age (Louette, Krahn, Caine, Ha, Lau, & Singh, 2018).

Individuals who are younger can also develop epididymitis. Individuals who are at risk for developing epididymitis include those with a blockage in the urethra, those with chlamydia or other sexually transmitted diseases, and those with a traumatic groin injury or the chronic use of a catheter. Symptoms of epididymitis include scrotal pain, edema and erythema in the testicle, fever, and pain with urination. The diagnosis of epididymitis will include a thorough health history and physical exam, urinalysis, and also a scrotal doppler ultrasound. Treatment of epididymitis will include antibiotic therapy, over-the-counter pain medication or prescription anti-inflammatories, bed rest, scrotal elevation, application of cold therapy, and the avoidance of lifting heavy objects. This is not the likely diagnosis for C.M. . because his urinalysis was normal. And although his scrotal doppler ultrasound showed absent blood flow to the left testicle, this is still not his likely diagnosis.

Plan: Consults: A Urologist consult is necessary for him due to him most likely requiring surgical treatment for his diagnosis of testicular torsion. Although at times the urologist can manually untwist the spermatic cord, surgical repair is always necessary to prevent the torsion from occurring again.

Therapeutic modalities: First and foremost, the child will need to be sent to the emergency department for a urologist surgical consult for surgical detorsion of the left spermatic cord to restore blood supply and must most optimally be done within 6 hours of onset of pain.

The child will need to be NPO Pharmacological: Morphine 0.2 mg/kg dose max of 4 mg (patient is 55 kg) 4 mg IV every 4 hours PRN pain Zofran (0.15mg/kg, 0.15 x 55 kg with a max of 4 mg) 4 mg IV every 4-8 hours as needed for nausea and vomiting

Nonpharmacologic: Rest Ice or cold pack therapy Scrotal support and elevation

Health Promotion: Continue recommended vaccinations as indicated per the CDC guidelines.

Continue yearly for a well check or return sooner if concerns arise.

Recommend that the child receives a yearly flu vaccine.

Return to the Urologist per their recommendations Eat a healthy diet with fruits, vegetables, low fat foods, and whole grains Patient education: The boy and his family should be educated on testicular torsion and how to properly recover. He should also be educated on not ignoring genital or groin pain. They should also be given education on all medications that are prescribed.

Education on a diet with an abundance of fruits, vegetables, whole grains, and healthy and lean meats and proteins is essential for optimal health. The patient should also have education on the addition of nonfat or low-fat dairy and the reduction of foods high in sodium also will work toward a healthier heart and body. This will also reduce inflammation in the body.

If okayed by his urologist/surgeon education on slowly restarting physical activity should also be given.

Disposition/follow-up instructions: The patient should return in 2 weeks following discharge from the hospital to ensure the prescribed treatment and education is effective for the patient.

Go to the ED or Urgent Care or the clinic if: -If C.M. vomits and it will not go away -If nausea and vomiting does not subside with treatments or rest, or gets severe despite prescribed medication, stops then returns.

-If he feels lightheaded or dizzy -If he develops pain the abdomen -Extreme drowsiness or confusion

- fever of 100.5 or higher -difficulty with urination

- If pain or swelling, testicular shrinking, or bleeding that won’t stop following surgery.

Performance view case week #10 13-year-old boy by ……..

I

History Notecard

Use this worksheet to organize your thoughts before developing a differential diagnosis list.

Indicate key symptoms(Sx) you have identified from the history. Start with the patient's reason(s) for the encounter and add additional symptoms obtained from further questioning.

2. Characterize the attributes of each symptom using "OLDCARTS". Capture the details in theappropriate column and row.

3. Review your findings and consider possible diagnoses that may correlate with these symptoms. (Remember to consider the patient's age and risk factors.) Use your ideas tohelp guide your physical examination in the next section of the case.

1.

HPI

Sx

Onset Location Duration Characteristics Aggravating Relieving Timing

/

Treatments Severity

=

Sx

=

Sx

=

Sx

=

Sx

=

Sx

=

Problem Statement A 13-year-old male with sudden onset of 9/10 left testicular pain while playing basketball, he experienced some nausea and vomited once. On physicalassessment, he is tachycardic, diaphoretic, and restless. Genital exam is significant for left hemiscrotum and scrotum erythematous and swelling, a negative Prehn’s sign, an absent left cremasteric reflex, and significant discomfort when the testicle is touched. Pertinent negatives include afebrile, abdominal pain, or urinary difficulties.

II

Management Plan

Diagnostic Tests Scrotal US, doppler: Absence of blood flow to the left testicle.

CBC: Mildly increased total WBC without left shift.

UA: Normal.

CT ABD/Pelvis w/o contrast: Negative.

Medication None, the emergency department provider and surgeon will manage any medication needed.

Consults/Referrals I have contacted the emergency department provider, and they are expecting you. Please report directly to the emergency room for further management. Discussed with the father about transporting the patient in a private car to the emergency department instead of calling for an ambulance. Father understood the importance of taking him directly to the emergency room. The emergency provider will be contacting the on-call urologist as testicular torsion is a medical emergency, and immediate attention is required.

Client Education The urologist will be consulted to determine if manual detorsion is appropriate. However, you will likely have surgery and should not consume anything to eat or drink until permitted to do so by the surgeon/urologist.

Follow-Up Follow up with surgeon/urologist as directed.

Follow up with PCP as needed.

III Electronic History of

Present Illness

Category Reason for

Health Record

Data entered by …….

Encounter

Testicular

pain

History of

Category

present illness

A 13-year-old male who presents to the office for a sudden onset of testicular pain. He reports that the pain started about two hours ago when he was playing basketball.

He denies any physicaltrauma to the area. He reports the pain is a 9/10 out of a 1-10 scale and describes the pain as a being punched feeling. He reports it hurts to move and walk. The pain is constant.

Denies any alleviating factors. Has not taken any medication.He reports he vomited once on the way to the office. Denies any blood or pain with urination.

Data entered by ….

Father (49), hypertension. Mother (48) problems.

Siblings: sister

Family History Past

Medical

has no (9) healthy.

medical

pediatrician.

Immunizations

History

Category

Data entered by ……

Past

None

MedicalHistory

Hospitalizations/ Surgeries

Tympanostomy tubes

Medications Category

Data entered by …..

Medications

None

Allergies Category

Data entered by …..

Allergies

None

Preventive

Health

Category Preventive Family History

Data entered by …. health

Has

had up

regular checkups to date for

with age.

Social History Category

Data entered by …..

Social History

Marital status/personal supportsystem: dependent adolescent.

Housing: Lives in a single-family home with sister and both parents.

Occupation: middle-school student.

Substance use: Denies tobacco, alcohol,and substances.

Pertinent Sexual History: Not sexuallyactive.

Review of

other

Systems

Category

Data enetered by ……

General

Denies any problem sleeping. unintentional weight loss or night sweats.

Integumentary /

HEENT /

Neck

Breast

Denies any hair

itchy or

scalp, skin brittle nails.

Denies any gain, denies

changes,

fatigue, fever, and

moles, thinning

Denies any headaches or double or blurred vision.

Denies any difficulty with night vision, problems hearing, ear pain, sinus problems, chronic sore throats,or difficulty swallowing.

Cardiovascular

Denies chest pain, discomfort, or pressure.

Denies pain/pressure/dizziness with exertion or anger. Denies palpitations, blue/cold fingers or toes, denied any change in exercise tolerance.

Respiratory

Denies any shortness of cough, sputum production, his breath.

Gastrointestinal

Reportsvomiting indicatehe normal bowel diarrhea, tarry or bloating

breath, wheezing, or any difficulty

chronic catching

on the way to appointment still doesn’t feel well. Reports had movement last night. Denies any constipation, coffee grounds like vomit, dark bright red blood in stool, denies or early satiety.

Genitourinary

Reports sudden onset difficulty

Musculoskeletal

Denies muscle and joint pain. Denies redness, swelling, muscle cramps,joint stiffness/swelling/redness. Denies back, neck, shoulder, hip, or leg pain.

Allergic /

of left urinating.

testicular

pain.

Denies any

Immunologic

Endocrine

Denies any heat or cold intolerance, increased or sweating.

Denied any urinary frequency.

Denied any change in urine color.

Hematologic / Lymphatic

Denies any other

Neurologic

Denies any dizziness, fainting, tingling,tremor, seizure or spinning

Psychiatric

Denies nervousness, depression, sadness, memory Denies hearing voices or there.

Physical

bruising, sites of

bleeding increased

gums, nose bleeding.

thirst

bleeds, or

weakness, numbness, room feeling.

lack of interest, loss or mood changes. seeing things that are not

Exams

Category

Data entered by ……

General

Looks uncomfortable, appearsstated age, appropriately for the weather.

well-groomed, dressed

Skin

Skin:

noted on

face

murmurs,

heaves, thrills,

HEENT /

Neck

Cardiovascular

Chest /

Respiratory

Warm, mildly diaphoretic. back, no rash.

Acne

Pupils: equal, round, reactiveto

light.

Tachycardic or

no

No

120 bpm, bruits heard.

adventitious

lung

sounds heard throughout.

and

Abdomen visible to or

Abdomen

Genitourinary /

Rectal

is lean, muscular, and non-distended, no herniation.

Bowel sounds active. Soft, nontender palpation.

No organomegaly; no abdominal inguinal mass. ABD normal to percussion.

Left

hemiscrotum is swollen and mildly erythematous. Left testicle appearshigher than the right; scrotum is too swollen to determine testicular lie.

Left testicle:exquisitely tender to touch; no masses appreciated. Absent left cremasteric reflex; right WNL. Negative Prehn’s sign. Tanner stage 3; circumcised, no penile discharge.

No rash or lesions.

Musculoskeletal / Osteopathic Structural Examination

Deferred.

Neurologic

Deferred.

Psychiatric

Deferred.

Lymphatic

No

inguinaladenopathy.